Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools

Background: The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety climate in healthcare organizations; however, the rigour with which safety climate tools were developed and psychometrically tested was shown to be variable. This paper aims to identify and review questionnaire studies designed to measure safety climate in acute hospital settings, in order to assess the adequacy of reported psychometric properties of identified tools. Methods: A systematic review of published empirical literature was undertaken to examine sample characteristics and instrument details including safety climate dimensions, origin and theoretical basis, and extent of psychometric evaluation (content validity, criterion validity, construct validity and internal reliability). Results: Five questionnaire tools, designed for general evaluation of safety climate in acute hospital settings, were included. Detailed inspection revealed ambiguity around concepts of safety culture and climate, safety climate dimensions and the methodological rigour associated with the design of these measures. Standard reporting of the psychometric properties of developed questionnaires was variable, although evidence of an improving trend in the quality of the reported psychometric properties of studies was noted. Evidence of the theoretical underpinnings of climate tools was limited, while a lack of clarity in the relationship between safety culture and patient outcome measures still exists. Conclusions: Evidence of the adequacy of the psychometric development of safety climate questionnaire tools is still limited. Research is necessary to resolve the controversies in the definitions and dimensions of safety culture and climate in healthcare and identify related inconsistencies. More importance should be given to the appropriate validation of safety climate questionnaires before extending their usage in healthcare contexts different from those in which they were originally developed. Mixed methods research to understand why psychometric assessment and measurement reporting practices can be inadequate and lacking in a theoretical basis is also necessary

'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice

Background: Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks. Methods: A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed. Results: Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment. Conclusion: The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so

Understanding and responding when things go wrong: key principles for primary care educators

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a ‘systems approach’ could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a ‘Just Culture’ where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame ‘human error’. System complexity makes reduction into component parts difficult; thus attempting to ‘find-and-fix’ malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a ‘systems approach’ that can increase learning and reduce the damaging effects on morale when ‘human error’ is blamed. This may result in ‘human error’ becoming the starting point of an investigation and not the endpoint

Understanding patient safety performance and educational needs using the ‘Safety-II’ approach for complex systems

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners’ curriculum. Current methods that are taught and employed to improve safety often use a ‘find-and-fix’ approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with ‘traditional’ methods to enhance patient safety training, outcomes and curriculum coverage

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board

Introduction: Wrong-site/side surgical "never events" continue to cause considerable harm to patients, healthcare professionals, and organizations within the United Kingdom. Incidence has remained static despite the mandatory introduction of surgical checklists. Operating theater list errors have been identified as a regular contributor to these never events. The aims of the study were to identify and to learn from the incidence of wrong-site/side list errors in a single National Health Service board. Methods: The study was conducted in a single National Health Service board serving a population of approximately 300,000. All theater teams systematically recorded errors identified at the morning theater brief or checklist pause as part of a board-wide quality improvement project. Data were reviewed for a 2-year period from May 2013 to April 2015, and all episodes of wrong-site/side list errors were identified for analysis. Results: No episodes of wrong-site/side surgery were recorded for the study period. A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). There was considerable variation in incidence between surgical specialties with ophthalmology recording the largest proportion of errors per number of surgical cases performed (1 in 87 cases) and gynecology recording the smallest proportion (1 in 2671 cases). The commonest errors to occur were "wrong-side" list errors (62/86, 72.1%). Discussion: This is the first study to identify incidence of wrong-site/site list errors in the United Kingdom. Reducing list errors should form part of a wider risk reduction strategy to reduce wrong-site/side never events. Human factors barrier management analysis may help identify the most effective checks and controls to reduce list errors incidence, whereas resilience engineering approaches should help develop understanding of how to best capture and neutralize errors

A synthetic biochemistry platform for cell free production of monoterpenes from glucose.

Cell-free systems designed to perform complex chemical conversions of biomass to biofuels or commodity chemicals are emerging as promising alternatives to the metabolic engineering of living cells. Here we design a system comprises 27 enzymes for the conversion of glucose into monoterpenes that generates both NAD(P)H and ATP in a modified glucose breakdown module and utilizes both cofactors for building terpenes. Different monoterpenes are produced in our system by changing the terpene synthase enzyme. The system is stable for the production of limonene, pinene and sabinene, and can operate continuously for at least 5 days from a single addition of glucose. We obtain conversion yields >95% and titres >15 g l-1. The titres are an order of magnitude over cellular toxicity limits and thus difficult to achieve using cell-based systems. Overall, these results highlight the potential of synthetic biochemistry approaches for producing bio-based chemicals

The pattern of symptoms in patients receiving home based care in Bangwe, Malawi : a descriptive study

Abstract Background Home based care of HIV/AIDS patients is a health need recommended but not often available in Africa. Population based assessment helps to identify unmet health needs to plan services. Careful assessment and follow up of patients receiving home based care in a defined population of Bangwe, Malawi provides details of the frequency and severity of common symptoms. Methods Mortality and the incidence, duration and severity of common symptoms of patients in a defined population receiving home based care were measured over an eighteen month period. Results 358 patients, of whom 199 died, were studied. A third of patients died within 4 months of being first seen. About half the patients were unable to care for themselves on first assessment. Half were malnourished with a Body Mass Index (BMI) &lt; 18.5 kg/m2. Most patients had a mixture of symptoms at presentation. These symptoms responded to treatment usually within a fortnight. However a small proportion (5%) of patients suffered repeated episodes often as many as 6–9 times a year. Incidence rates are estimated. Conclusion Symptoms which are alleviated by simple treatments are common. The patients in whom symptoms recur need a responsive home based care service. Population based estimates of incidence and duration of disease and the visit work load allow an assessment of home based care needs in an urban setting in Africa. </jats:sec

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model

Objectives To analyse a medical protection organisation's database to identify hazards related to general practice systems for ordering laboratory tests, managing test results and communicating test result outcomes to patients. To integrate these data with other published evidence sources to inform design of a systems-based conceptual model of related hazards. Design A retrospective database analysis. Setting General practices in the UK and Ireland. Participants 778 UK and Ireland general practices participating in a medical protection organisation's clinical risk self-assessment (CRSA) programme from January 2008 to December 2014. Main outcome measures Proportion of practices with system risks; categorisation of identified hazards; most frequently occurring hazards; development of a conceptual model of hazards; and potential impacts on health, well-being and organisational performance. Results CRSA visits were undertaken to 778 UK and Ireland general practices of which a range of systems hazards were recorded across the laboratory test ordering and results management systems in 647 practices (83.2%). A total of 45 discrete hazard categories were identified with a mean of 3.6 per practice (SD=1.94). The most frequently occurring hazard was the inadequate process for matching test requests and results received (n=350, 54.1%). Of the 1604 instances where hazards were recorded, the most frequent was at the ‘postanalytical test stage’ (n=702, 43.8%), followed closely by ‘communication outcomes issues’ (n=628, 39.1%). Conclusions Based on arguably the largest data set currently available on the subject matter, our study findings shed new light on the scale and nature of hazards related to test results handling systems, which can inform future efforts to research and improve the design and reliability of these systems

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams

Objectives: To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. Design: Qualitative study using semistructured interviews. Data were analysed thematically. Subjects and setting: Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. Results: 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. Conclusions: The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted

A systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge

BACKGROUND Pharmacists’ completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload. DESIGN Systematic literature review and meta-analysis of extracted data. METHODS Medline, CINHAL, EMBASE, AMED, ERIC, SCOPUS, NHS evidence and the Cochrane databases were searched using a combination of Medical Subject Heading (MeSH) terms and free text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using CASP. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively. RESULTS Fourteen studies were included comprising five RCTs, six cohort studies and three pre-post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload. CONCLUSIONS Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload